INTRODUCTION

Self-care is a relevant concept in Nursing, especially since the presentation of the Self-Care Theory by Dorothea Orem in 1971(1). This Nursing Theory is a scientific pillar of practice for building the quality of nursing care(2).

The International Council of Nursing, in 2005, defined self-care as the set of activities necessary for the person to maintain their life and well-being, as well as to manage their individual needs and Activities of Daily Living (ADL)(3). Self-care is intrinsic to the person and depends on their uniqueness(3).

The assessment of self-care ability is transversal to all nurses, but it represents a clinical decision area with special relevance for the practice of Rehabilitation Nursing (RN)(4,5). Rehabilitation emerges at a transition point of self-care, depending on the person's autonomy and freedom to make decisions regarding their Health Project(6).

The Specialist Nurse in Rehabilitation Nursing (SNRN) has three pillars in their praxis: caring, training and maximizing(7). In this perspective, the SNRN can temporarily or permanently replace the person in carrying out ADLs and/or carry out interventions that enhance the person's functionality to carry out self-care(8), transmitting knowledge and training skills in this process of the person and/or formal caregivers or informal, to carry out autonomous and independent self-care.

Currently, health gains can be evaluated through indicators, and self-care is a privileged area in the monitoring of health gains related to the nursing care provided. These favor the promotion of autonomy/independence and the development of unique abilities and/or of caregivers(9,10).

It is fundamental to understand the predictive indicators of self-care since they designate the prediction of a person's behavior about a self-care activity(11). These indicators influence the person's responsibility and ability to perform self-care actions(12). The identification of predictive indicators of self-care is the basis of the Nursing Process since an efficient initial assessment allows the elaboration of a valid care plan(13-15).

Dorothea Orem presupposes the existence of requirements and conditioning factors of self-care, but that deviate from the common citizen's sense(16). Recently, a holistic person-centered model was developed by Narasimhan, Allotey, and Hardon, which emphasizes the importance of educational strategies and adaptation to transitions to promote self-care but does not clarify the predictive indicators of self-care(17). From the research carried out by the authors on self-care, it was not possible to identify a structured core of predictive self-care indicators that support the clinical decision. On the other hand, there are several studies on the indicators of adherence to the therapeutic regime in relation to pathologies such as Diabetes Mellitus or Hypertension, but without addressing the predictive indicators of self-care.

A gap in the literature was thus identified, which gave rise to the research question with a variant of the PICO methodology, the “PO” (population/outcome, phenomenon): “What are the predictive indicators of the self-care capacity (O) of the adult person (P)?". The following aims were defined for this study:

METHODOLOGY

A Systematic Literature Review (SLR) was carried out to identify the predictive indicators of adult self-care capacity and the evaluation methods used by rehabilitation nurses. The SLR allows for identifying, evaluating, and synthesizing the results of several preponderant studies carried out in the health area, on a specific theme^18,19.

A specific protocol with PRISMA design was built, in order to become scientifically solid and to minimize obstacles that deteriorate the final result of the RSL^20,21. Thus, the descriptors were selected using the DeCS/MeSH nomenclature: (Adult), (Self Care), (Nursing), (Self Management), (Indicators), (Rehabilitation), formulating the Boolean equation used for research: (Self Care) AND (Indicators).

It was decided to define the time limit from September 1, 2011, to September 30, 2021, to cover more studies on the subject. The EBSCO Host database platform was consulted by 2 reviewers, with simultaneous access to the following databases: CINAHL Complete, MEDLINE Complete, Nursing & Allied Health Collection: Comprehensive, Cochrane Central Register of Controlled Trials, and MedicLatina. Only full-text articles in Spanish, English, or Portuguese were considered. All remaining articles were excluded.

Titles and abstracts were read, looking for primary studies and referring to at least 2 defined descriptors. By applying these criteria, eliminating duplicate articles, and excluding articles without an abstract

Afterward, the articles were read in full, with the definition of the inclusion criteria: approach in the body of the text of self-care indicators of the adult person or methods of evaluating the self-care capacity of the adult person.

The next step consisted of the qualitative analysis of the selected studies, by 3 reviewers, to confidently select the final body of the study. The Critical Appraisal Tools of the Joana Briggs Institute (CAT-JBI) of qualitative studies, cohort studies, and cross-sectional studies were used, to admit studies of validated scientific quality. High-quality studies were defined as acceptance criteria, with a classification equal to or greater than 75% in the CAT-JBI. The level of evidence was classified by the JBI²².

RESULTS

From the research carried out, 620 articles were identified. After reading the title, the sample was reduced to 41 articles. Afterward, the articles were read in full, and after applying the eligibility criteria, the sample was reduced to 9 articles. Two studies were excluded, as they presented a classification lower than 75% of the JBI criteria. The final body of studies was reduced to 7, being exposed in the Methodological Path of Selection of Articles (Figure 1).

Figure 1 Identification, Selection, and Inclusion of Articles Path. 

Subsequently, the data identified in the studies were analyzed based on the assumptions of the International Classification of Functioning, Disability and Health (ICF)²³, since it provides a scientific basis for understanding and studying health determinants, as well as allowing the establishment of a Universal language.

In the following table, the results referring to the Selected Studies are explained (Table 1) to facilitate the analysis of their results. These studies form the core of SLR. The studies were developed in 5 European countries, China, and Canada, and presented a CAT-JBI level of evidence above 80%.

Subsequently, each selected study was read in full, extracting the data presented in Table 2, to proceed with their synthesis and critical and qualitative analysis.

After identifying the data, three classes of indicators were considered, to facilitate the understanding, and systematization of the data. These classes allow the Nurse to have a guide for assessing the person's self-care capacity. Then there are the following classes:

Personal Indicators are contemplated as Intrinsic Indicators to the person, while Organizational Indicators and Social Indicators refer to Extrinsic Indicators. The ICF also advocates the influence of Facilitating Factors and Barrier Factors (complicating factors) in activities²³. In Table 3, data from the survey results were grouped by Indicator Class, Factor and Dimension.

A table was also created with the main data on the identified Self-Care Capacity Assessment Instruments (Table 4). The studies identified in this SLR do not deeply address how each Assessment Instrument is applied, so the data were complemented by consulting other studies.

DISCUSSION

Most studies allowed the identification of several predictive indicators of self-care with facilitating or barrier factors in the self-care capacity of the elderly person^11,26-29. However, two of the studies present only barrier factors^24,25.

The person has a greater capacity for self-care when he manages his life autonomously and in his own home, without interference from third parties^11,27. There is a greater predisposition to perform quality self-care activities when there is free time (for example, retired person), psychological and physiological well-being, and ability to understand life situations, illness and self-care^11,27,28,35. The SNRN can intervene at any time of the life cycle, playing, mainly, the role of guiding the person in promoting the person's autonomy, and independence through the identification of special intervention and learning needs⁷.

It is fundamental for institutions to create activities with the involvement of Nurses and, particularly, SNRN that promote the functional readaptation of the adult person in a transition situation, to live in fullness, with privilege for acceptance and adaptation to their state of health^{(7, 26)}. Health education sessions should be prepared that are of the person's real interest and need, with time adjusted to their training needs, and with consideration for their knowledge/competence²⁶.

Health literacy is mirrored as a facilitating factor of self-care ability in two studies presented^11,27. However, illiteracy in health and low levels of education may compromise the understanding of readaptation strategies, leading to incapacity for self-care^25,27,29. Decreased understanding of the disease may also lead to an erroneous perception of the state of health, making efficient self-management, recovery, and/or rehabilitation of the person more difficult²⁹.

The SNRN has to consider these aspects in health education sessions, whether individual or group intervention, as it is a specific competence of the SNRN⁸. The person's training process should be seen as a sharing of desires for the person and knowledge about techniques and/or skills by the SNRN, in order to promote their functional readaptation due to disability, limitation of activity and/or restriction of participation in their activities^8,26.

Active aging appears in these studies as an Organizational and Social Indicator, since it is seen as an opportunity that institutions offer to the elderly to maintain and develop their abilities, providing their social inclusion and encouraging them to develop skills to live in peace. community^11,29,35,36. This concept is very practical and aims to allow the elderly to participate in social and leisure activities that provide a better perception of health and life habits^11,27,35. It is a facilitating factor in carrying out ADLs, which are directly related to the implementation of self-care^36,37.

In these studies, the impact of Social Indicators on the willingness to carry out self-care activities is evident. People feel more comforted if they have a strong family support network^11,38. On the other hand, the extended social support network is also crucial, for example, through the testimony of people who experience similar situations²⁹. Empathy and interpersonal relationships facilitate the person's maintenance or development of motivation^11,29,38. Another study carried out in Portugal validates these data, as the family facilitates the well-being, and enhances the capabilities of the elderly³⁵.

It was not possible to identify Organizational and Social Indicators with a barrier effect on self-care ability. It appears that the absence of facilitating indicators of self-care capacity constitutes a barrier factor. The barrier factor with the highest incidence in the studies is age greater than or equal to 65 years old since it is related to the occurrence of chronic diseases, and comorbidities in the elderly population ^11,27,39. The aging process is reflected in greater vulnerability to internal and external factors, associated with the frailty of the elderly⁴⁰. Several signs and symptoms predict disability in self-care, especially unintentional weight loss, fatigue, decreased fine motor skills, reduced physical activity, and decreased gait speed^11,28,29,40.

The decline in mental health is also associated with the inability to self-care, as there is a direct relationship between mental health and the ability to solve everyday problems/situations^11,25. The balance of this relationship is affected by problems such as depression and anxiety^11,24,28, which reduce the person's ability to concentrate and self-management²⁴.

Living in residences and homes affects the person's autonomy because the person is not exclusively responsible for managing self-care, which may lead to a decrease in self-care capacity²⁷. The Nurse has to consider this factor, to promote the exercise of autonomy and decision-making of the person⁷.

Once the predictive indicators of the person's self-care ability are identified, it is possible to outline strategies to maximize the facilitating factors and remove, minimize, or overcome the identified barriers, aiming to maximize the person's functionality and develop their abilities in the various levels of competence^{(7, 15.23)}. The Nurse considers these indicators in the evaluation phase of the Nursing Process^13,14.

Regarding self-care capacity assessment methods, several Self-Care Capacity Assessment Instruments were identified. The Assessment Instruments allow for assessing needs, diagnoses and predicting the results of the Nurses' care^14,15. In these studies, 4 Assessment Instruments were identified that allow the objective assessment of self-care capacity: SASE, ASA, NUFFE¹¹, and SHDE²⁷.

SASE is validated for universal use³⁰. The ability to achieve goals is the main construct of SASE, since it is through the establishment of goals that the person manages to outline their self-care practice. The repertoire capacity consists of the set of knowledge and skills that the person possesses and recruits to perform self-care activities. The ability to achieve well-being is related to the person's satisfaction and quality of life³¹. The SASE has not yet been validated for the Portuguese context, so further research on this topic is recommended.

The ASE presents questions directly related to self-care ability, self-care inability, and development of self-care ability, to identify which of the 3 categories the person identifies with most³². The use of SASE and ASE allows the perception of the person's self-care ability, and their classifications are predictive of self-care ability^30,32. The ASE has been translated into Portuguese but has not been validated for the Portuguese population⁴¹.

The NUFFE is a validated questionnaire for use in the rehabilitation plan^11,33. However, it should be used by professionals with in-depth knowledge of nutrition³³. High self-care ability is estimated with high scores on SASE, and ASA, low scores on NUFFE¹¹, and Responsible Self-Care Profile on SHDE²⁷.

SHDE has not been fully validated yet for use in the Portuguese population^12,27. In the study presented in this SLR, it was not possible to define the Self-Care Profile of 71 of the 122 participants in the study²⁷.

Regarding each type of Self-Care Profile, the person who presents the Responsible Self-Care Profile reveals interest in their Health Project, and cares about self-care, idealizing life, health, and the future with optimism²⁷. The person with this profile is responsible and performs ADLs, seeks knowledge about their health status and shows the ability to make decisions^12,34,42.

In the study on Self-Care Profiles, no information is presented on the Formally Guided, and Independent Self-Care Profiles, constituting a limitation of this study²⁷. The original publication of the model was consulted to understand these profiles³⁴. The Formally Guided Self-Care Profile is adopted by people with little knowledge, but who are concerned with their life, health, and self-care, following the nurses' instructions even if they do not understand them. Regarding the Independent Self-Care Profile, the person believes he has the necessary tools and knowledge, devaluing the nurse's intervention³⁴.

The Abandonment Self-Care Profile is presented as a barrier to self-care ability. This profile is characterized by low adherence to the therapeutic regime, lack of a Health Project, devaluation of self-care, and a tendency towards social isolation^12,27,34. The person is powerless to manage their life and health, lack of responsibility, illiteracy in health, depression, insecurity, fear of death, and may have a disability^27,42. It is necessary to accompany this person throughout life, to provide support and supervision, minimizing the negative impact on self-care³⁴.

Although this review does not present the results of the Assessment Instruments with a barrier effect on self-care ability, it appears that it constitutes a barrier factor when the opposite result is verified in the Assessment Instruments. Also, not all types of ADL, described by the OE, with an impact on self-care are presented⁴³. The focus on food stands out since it has been widely studied in Diabetes Mellitus, which is a disease with a high incidence in studies of this SLR and with specific Assessment Instruments.

SLR has several limitations, which are named below:

CONCLUSION

In this SLR, 3 classes of predictive indicators of self-care ability were identified: Personal, Organizational, and Social. The studies emphasize the relevance of Personal Indicators, considering that the prediction of self-care ability is essentially intrinsic to the person himself. In this way, they are considered in the evaluation of the person and may present facilitating or barrier factors.

The use of the Assessment Instruments complements the person's assessment, also using them to monitor self-care ability. The assessment of the self-care capacity of the elderly can be performed using the SASE and ASA scales. The SHDE, despite presenting content with apparent importance in the prediction and assessment of self-care ability, should be used with caution in Portugal as it has not yet been fully validated in the Portuguese context.

All Nurses and, above all, the SNRN will be able to use these Indicators and Assessment Instruments in their practice to predict self-care ability, finding a balance between facilitating and barrier factors, to maximize the person's functionality and self-care ability.

It should be highlighted the emergence of several opportunities for scientific research, namely: